The Future of the ACA

Since first running for office, President Donald Trump made it clear that he was not in favor of the ACA and he and the Republican party have made several, mostly unsuccessful, attempts to repeal and replace the plan since he took office.

Among efforts to undermine the ACA, the Trump Administration has reduced or eliminated the federal role in administering certain individual markets and created an alternative individual health insurance market independent of the ACA.

Last year, the Trump Administration passed a tax bill that eliminated the ACA’s tax penalty for not obtaining health coverage that took effect in 2019, impacting the ACA marketplaces and possibly reshaping how Americans will get health insurance in the years ahead.

Then in December, Texas U.S. District Judge Reed O’Connor declared the ACA unconstitutional, and though his decision was stayed pending an appeal and many believe that the judge’s ruling won’t stand, it has caused some states to take steps to protect the ACA.

If his decision is upheld, approximately 10 million people on Medicaid would be left uninsured. As the ACA protects those with preexisting health conditions and without the law, those who suffer from disabilities, chronic illnesses and rare diseases will have a difficult time receiving private coverage.

So where does that leave the ACA in 2019?  David Prescott, PhD, assistant professor and the director of the Health Administration and Public Health program at Husson University, says-as the history of the ACA already suggests-one predicts the future of ACA at one’s peril.

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“Already the law has been challenged in the Supreme Court, enacted at different levels by different states, and changed from its original form,” he says. “Currently, the major challenge to the law is whether the elimination of the requirement that all citizens must have health insurance (or pay a penalty) means that the entire ACA, as it now stands, is unconstitutional.” 

The challenge is that the number of uninsured Americans is starting to rise again and many experts argue over exactly why this is occurring. Regardless, Congress has not been able to develop consensus on a plan to scale back or eliminate ACA without putting a large number of Americans back in the uninsured category.

Daniel E. Trucil, a spokesperson for the American Geriatrics Society, says the organization continues to express concern for the future stability of high-quality, person-centered, and affordable health care should bipartisan collaboration falter when it comes to health reform.

“The ACA has improved access to health insurance for more than 20 million Americans through the expansion of Medicaid and the introduction of an insurance marketplace,” he says. “Several critical elements of the law serve the growing needs of older adults specifically, from the closing of the Medicare prescription ‘donut hole’ to the elimination of cost-sharing deductibles or copayments for vital preventive health services.”

For that reason, the organization believes the ACA can be improved and any future action on health reform must do all it can to protect high-quality, person-centered, and affordable health coverage.

So, while the ACA is under attack, it continues to be very valuable to the public and there is no serious alternative.

Theresa Hush, CEO of Roji Health Intelligence LLC, feels there will be continuing efforts in the administration to dismantle key provisions of the ACA, yet despite all the attempts to limit the ACA and to lower its marketing approach to the public, the program has held up remarkably well under pressure.

“It speaks to the demand of people to have healthcare in the U.S. that it has withstood the pressure,” she says. “We also know that there has not been a significant decrease in the number of people without insurance, despite the cost of procurement.” 

The importance of the ACA

Peter Hollmann, MD, chief medical officer for University Medicine, a Rhode Island-based academic and patient care medical group practice, and former medical director for Blue Cross and Blue Shield of Rhode Island for 20 years, says while there have been federal executive and legislative actions which have the potential to undermine the successes of the ACA, it remains the law and continues to benefit many citizens from those who never had coverage to those who had good coverage all along.

“It is a major contributor to insurance rate/cost stability across all segments: Medicaid, Medicare, Commercial Exchange/Individual and Small Group and traditional employer based self-insured and fully-insured products,” he says. “It creates a more level playing field and increases the pool of the insured. It has driven many delivery system reforms and changes that have improved quality and reduced what would have been even higher costs.”

Additionally, the ACA improves the health of communities which makes them more successful and productive and less subject to public health crises and epidemics and has been important to saving safety net providers (hospitals, health centers and professionals) by improving their revenue. 

“Any repeal by legislation or judicial act is fraught with peril as many financial and other changes are set in motion,” Hollmann says. “One cannot simply undo the law, but a very complex unwinding would be necessary.”

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Sapan Desai, MD, Northwest Community Healthcare in Arlington Heights, Illinois, and a consultant to major healthcare corporations, says the future of ACA is really dependent on a data-driven approach to healthcare. For instance, the use of sophisticated data analytics tools, such as the QuartzClinical cloud-based platform or the IBM Truven platform, will continue to accelerate the discussion around high-quality care for a low cost.

“As we continue to transition away from a fee for service model to a value-based model that emphasizes high-quality healthcare, the industry is seeing numerous trends in medicine,” he says. “First, physicians are now acutely aware of how long their patient stays in the hospital, whether or not they are readmitted, and also what the cost of that care is. The drive has been to continue to improve the quality of care provided while decreasing costs. This trend will continue to accelerate in 2019.”

Don’t give up

John Baackes, CEO of L.A. Care Health Plan, the largest publicly-operated health care plan in the country, says the ACA is still alive and going strong.

“The two setbacks that we’re dealing with now are the loss of the tax to enforce the mandate and what impact that might have on the individual market,” he says. “Our experience here is that we have continued to grow our exchange product line [in the individual market] and so we are not quite sure how that loss of the tax as an incentive for the mandate is really going to play out.”

While he admits that the other hangover is the case in Texas and the intervention by the new House of Representatives to have that overturned, Baackes believes it is somewhat of a distraction-common opinion among many in the health care industry is that the judge’s logic in coming up with his ruling is flawed and will not be sustained.

“I think ‘repeal and replace’ is dead and this Texas court ruling is the last time we’ll deal with this,” he says. “I do think most politicians are looking at how to make healthcare even broader, in terms of the government’s role, which is why you see all the progressive campaigning on Medicare-for-all or single payer. I think that will not prevail.”

Related article: Medicare for All: Four Things Health Executives Should Know

Instead, Baackes believes they will go back to the ACA and finally begin to address improvements to the plan or make technical amendments that have not been addressed since the bill was passed because of the constant drumbeat of “repeal and replace.”

“Our organization, as primarily a Medicaid managed care plan, has to make sure that we protect access to care for our members, and protect adequate funding to keep the program going,” he says. “We view all of this activity going on as potentially threatening. We do see plenty of opportunities for improvement.”

For example, California Governor Gavin Newsom has proposed a number of things that are favorable to making sure there is access to affordable healthcare for more people and is taking a hard look at how it’s going to sustain Medicaid funding in the long run.

Among his sweeping proposals are a Medi-Cal expansion that would cover young immigrant adults who are in the U.S. illegally; making it a requirement for all consumers in the state to carry health insurance; and increasing subsidies for middle-class families to help those who need it.

“Most people think of the individual markets as the biggest part of the ACA, but the biggest impact was really the expansion of Medicaid, so making that expansion sustainable over time is critical,” Baackes says. “California relies on a lot of well-thought-out, but incredibly complex, ways to fund Medi-Cal (that state’s name for Medicaid). And it’s all around making sure the state’s contribution or the state’s share of Medi-Cal, which is a shared expense with the federal government, is sustainable.”

Baackes would like to see all states bring back the mandate penalty, and restore the cost-sharing reduction (CSR) payments. However, he thinks the main focus should be on the states that did not expand Medicaid.

“A number of them have come back and tried to do the expansion through waivers, where they write the rules, and CMS says, ‘ok, you can do it this way in your state,’” he explains. “We must address the states that have held out and not done the expansion, because those states are losing out on federal funds, and in places like Texas, we still have an extremely high uninsured rate.”

Rosemarie Day, founder & CEO of Day Health Strategies, a Somerville, Massachusetts-based company that offers cost-effective consulting services to the health industry, believes the Texas ACA case will very likely be overturned and since there was no major movement on a complete ACA repeal last term, with the Democrats having a majority in the House now, it is even less likely that there will see successful efforts to repeal the ACA in 2019 or anytime soon.

“While the current administration has already taken action to weaken the ACA and the individual market, there are not many actions left that the administration can take to significantly degrade the law,” she says. “There needs to be continued focus on short-term health plans and other mechanisms that undermine the ACA. States have the authority to guard against these efforts to undermine the ACA by implementing restrictions on short term and association health plans and implementing a state level individual mandate.”

Rhode Island is one such state taking action to make key provisions of the ACA state law. Hollmann’s optimistic belief is that the ACA will remain and remain true to the key goals it represents, but that refinement will occur.

“We believe there is generally strong support of many key provisions and solid support of most. Effective legislative processes would improve weakness and address problems in the law,” he says. “Any law of this importance and scope has needed refinement. Medicare is constantly evolving, for example. When Medicare started, it did not include coverage for dialysis patients. Drug coverage is fairly recent in the life of Medicare.”

While some detractors have suggested a better law is possible, they must consider this position in light of generations of healthcare leaders and legislators who were never successful with coming up with much of anything at all after the creation of Medicare and Medicaid (including the children’s health insurance expansions).

Hush says that until there is a consensus for an alternative, she doesn’t see a lot of options for replacement.

“Medicare-for-All is the proposed solution by progressives, but there are significant obstacles to its passage,” she says. “I think it is more likely that some major parts of the ACA will be sustained, including expansion of Medicaid coverage, until we see health costs begin to rise dramatically again.”

The American Geriatrics Society’s view is that the threats to the law are not positive for anyone whether a Medicare recipient, their family member, their caregiver (e.g., healthcare worker for those who need assistance) or their hospital or doctor.

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“We need to strengthen geriatrics care and support lower paid workers who provide crucial services while barely able to support themselves,” Trucil says. “At least we can help them afford their own healthcare.”

Hollmann adds that the main point that is often overlooked is that this is not just about 26-year-olds, or poor people getting Medicaid or subsidized coverage: this law has benefitted everyone.

“It is not just about insurance,” he says. “It is about innovation, quality, and system change that is essential to preserve the economic growth and stability of our nation.”

Keith Loria is an award-winning journalist who has been writing for major newspapers and magazines for close to 20 years.